The keystone technique for resolution of chronic lower limb wound with lymphoedema

Abstract

This 32-year-old patient sustained a compound fracture of the lower limb at eighteen years of age. Over the last fourteen years he has had fourteen operations for the initial treatment of the compound tibia/fibula fracture to the sequence of complications resulting from unstable skin coverage over the distal third of the lower leg (see Figure 1). In July 2008 he was referred to our unit. The patient was most reluctant to have further surgery in view of the failed attempts to date. Preoperative angiograms indicated some limitations for microvascular reconstruction. Despite his ‘confidence’, the patient eventually agreed to further surgery. With chronic inflammation, surrounding tissue oedema and exposed tendons (tibialis anterior and extensor hallucis longus) after wound debridement, a keystone fasciocutaneous island flap over the superficial peroneal nerve (L5 dermatome) was planned. The operative sequence is detailed (see Figure 2). Figure 2a) Initial wound debridement. b) Keystone island flap designed over the lateral lower leg. c) Type IV keystone island flap transposed medially and grafted donor site. d) The leg wound fully healed approximately six weeks post-operatively. View Large Image Figure Viewer Download Hi-res image